This invention relates to making and using medically useful articles formed from hydrogels. More specifically, the present invention relates to the methods of using in situ hydration of hydrogel articles to seal or augment tissues or organs.
Hydrogels are materials that absorb solvents (such as water), undergo rapid swelling without discernible dissolution, and maintain three-dimensional networks capable of reversible deformation. See, e.g., Park, et al., Biodegradable Hydrogels for Drug Delivery, Technomic Pub. Co., Lancaster, Pa. (1993).
Hydrogels may be uncrosslinked or crosslinked. Uncrosslinked hydrogels are able to absorb water but do not dissolve due to the presence of hydrophobic and hydrophilic regions. A number of investigators have explored the concept of combining hydrophilic and hydrophobic polymeric components in block (Okano, et al., xe2x80x9cEffect of hydrophilic and hydrophobic microdomains on mode of interaction between block polymer and blood plateletsxe2x80x9d, J. Biomed. Mat. Research, 15:393-402 (1981), or graft copolymeric structures (Onishi, et al., in Contemporary Topics in Polymer Science, (Bailey and Tsuruta, Eds.), Plenum Pub. Co., New York, 1984, p. 149), and blends (Shah, xe2x80x9cNovel two-phase polymer system,xe2x80x9d Polymer, 28:1212-1216 (1987) and U.S. Pat. No. 4,369,229 to Shah) to form the xe2x80x9chydrophobic-hydrophilicxe2x80x9d domain systems, which are suited for thermoplastic processing. See, Shah, Chap. 30, in Water Soluble Polymers (Shalaby et al., Eds.), Vol. 467, ACS-Symp. Ser., Amer. Chem. Soc., Washington (1991). These uncrosslinked materials can form hydrogels when placed in an aqueous environment.
Hydrogels may be formed by physical or chemical crosslinking, or a combination of these two processes. Physical crosslinking takes place as a result of ionic linkages, hydrogen bonding, Van der Waals forces, or other such physical forces. Chemical crosslinking occurs due to the formation of covalent linkages. Covalently crosslinked networks of hydrophilic polymers, including water-soluble polymers are traditionally denoted as hydrogels (or aquagels) in the hydrated state. Hydrogels have been prepared based on crosslinked polymeric chains of methoxypoly(ethylene glycol) monomethacrylate having variable lengths of the polyoxyethylene side chains, and their interaction with blood components has been studied (Nagaoka et al., in Polymers as Biomaterial (Shalaby et al., Eds.) Plenum Press, 1983, p. 381). A number of aqueous hydrogels have been used in various biomedical applications, such as, for example, soft contact lenses, wound management, and drug delivery.
The concept of injecting hydrogels to fill spaces or tracks is described in U.S. Pat. No. 5,645,583 to Villain et al. That patent describes a polyethylene oxide gel implant that may be injected into a human body for tissue replacement and augmentation. U.S. Pat. No. 5,090,955 to Simon describes the use of gels in ophthalmology for corneal tissue augmentation procedures such as Gel Injection Adjustable Keratoplasty (GIAK). Neither patent mentions of augmentation of such tissue by hydration and swelling-induced shape changes in the tissue. Instead, for example, the Simon patent describes xe2x80x9csmoothing and massagingxe2x80x9d of the cornea to remove excess hydrogel material.
Non-degradable hydrogels made from poly(vinyl pyrrolidone) and methacrylate have been fashioned into fallopian tubal occluding devices that swell and occlude the lumen of the tube. See, Brundin, xe2x80x9cHydrogel tubal blocking device: P-Blockxe2x80x9d, in Female Transcervical Sterilization, (Zatuchini et al., Eds.) Harper Row, Philadelphia (1982), pp. 240-244. Because such hydrogels undergo a relatively small amount of swelling and are not absorbable, so that the sterilization is not reversible, the devices described in the foregoing reference have found limited utility.
U.S. Pat. No. 5,324,775 to Rhee et al. describes injectable particles based on swellable natural polymers that may be suspended in a non-aqueous fluid, e.g., an oil. The particles are formed from ground solid articles and may be injected into soft tissue to rehydrate in-situ to augment the tissue. A significant drawback of the compositions described in that patent, however, is the requirement that a non-aqueous and water insoluble carrier be used to inject the particles.
In view of the foregoing, it would be desirable to provide methods of using hydrogel materials, for example, for temporary occlusion of a body lumen or for tissue augmentation, that overcome the drawbacks of previously known compositions and methods.
It therefore would be desirable to provide methods of forming and using medically useful articles that comprise absorbable hydrogels, capable of undergoing a relatively large degree of swelling in-situ.
In addition to tissue augmentation and lumen occlusion, absorbable hydrogel articles may have application in sealing surgically created voids. For example, tissue biopsy is a very commonly performed minor surgical procedure, and is often to confirm or rule out the presence of disease that has been identified by a previously undertaken diagnostic modality, e.g., X-rays or ultrasound imaging.
Often needle biopsies are performed on solid organs using needles that are introduced from the outside of the patient""s body, across the pelvic or thoracic wall. Visualization in performing such procedures is typically limited and the cutting action of the needle often generates associated complications subsequent to the biopsy. Increasing experience with percutaneous biopsy has clarified some subtle points and controversies about possible complications and their prevention.
For example, while hemorrhage is possible with even the smallest aspiration needle, the risk has generally been assumed to increase significantly with the use of larger cutting needles and/or in patients with coagulation deficiencies. Some argue that the benefits attained with the use of cutting needles therefore is not worth the added risk. Unfortunately, while fine-needle aspiration techniques may provide the necessary tissue for cytologic diagnosis in many cases, there are situations in which cutting needles are needed for optimal diagnostic accuracy, such as biopsy of the retroperitoneum (when lymphoma is likely and must be typed) and in the diagnosis of unusual neoplasms, benign neoplasms, or diffuse hepatic or renal parenchymal diseases.
Even though needle biopsy is widely regarded as safe, often times leaks may develop in the underlying tissues due to the needle puncture. For example, when conducting a needle biopsy of the lung, air leaks may develop, leading to collapse of the lung and/or pneumothorax. The incidence of clinically significant pneumothorax following needle biopsy has been reported to be in the 15-25% range. Needle biopsy also is used to assess whether kidney transplantation has been successful, and is associated with the formation of arteriovenous fistulae in 10-15% of cases. Likewise, biopsy of the liver and spleen lead to bleeding complications in 5-10% of cases.
Liver biopsy is essential to the management of liver diseases. Although generally safe, the presence of a vascular tumor, bleeding diathesis or ascites makes the procedure more hazardous. The development of transvenous hepatic biopsy techniques have been one response to this problem. Prevention of hemorrhagic complications in high-risk patients has been accomplished with different clinical methods, and with varying degrees of success. Several authors have suggested use of a transjugular route for biopsy of the liver in high-risk patients. More recently, others have suggested that cutting needles may be used in conjunction with various methods to plug the needle track, for example, with steel embolization coils or gelatin sponge particles, such as GELFOAM(copyright), manufactured by Upjohn, Inc., Kalamazoo, Mich.
U.S. Pat. No. 5,522,898 to Bao describes a closure device for the repair of skin tissue, controlling bleeding, and reducing the likelihood of inducing excess scar tissue during a routine skin biopsy procedure, using a cylindrical tube made from a foam material which is absorbed in a biopsy site with little tissue reaction. That patent also describes the use of GELFOAM(copyright) for topical applications. While GELFOAM(copyright) may be effective in preventing bleeding, the sponge has a particulate structure, and is difficult to inject smoothly down a needle track. The risk of clumping and the subsequent scarcity of sponge along the needle track presents a risk of bleeding after non-uniform embolization.
Chisholm et al., in xe2x80x9cFibrin Sealant as a Plug for the Post Liver Biopsy Needle Track,xe2x80x9d Clinical Radiology, 40:627-628 (1989) propose the use of fibrin sealants to embolize a needle track. A drawback of this technique, however, is that fibrin sealants are associated with a theoretical risk of disease transmission due to the human and animal proteins that are the constituents of fibrin sealants.
Needle biopsies of other parenchymal tissues, such as kidney or lung tissue, also often result in prolonged hemorrhage or airleak from the site of the biopsy. This especially may present a problem when multiple biopsies are to be obtained from a particular organ.
It therefore would be desirable to provide hydrogel articles and methods for plugging voids created in tissue during surgical procedures, such as a needle track created during a biopsy, so as to reduce the risk of hemorrhage after tissue removal.
Abusafieh et al., in xe2x80x9cDevelopment of Self-Anchoring Bone Implants. I. Processing and Material Characterization,xe2x80x9d J. Biomed Mater Res., 38:314-327 (1997) describe the development of a self anchoring bone implant formed by polymerizing hydrogels around carbon and KEVLAR(copyright) fibers, a registered trademark of E. I. DuPont de Nemours, Inc., Wilmington, Del. The concept of self-anchoring swelling-type orthopedic implants is described by Greenberg et al. in xe2x80x9cStimulation of Bone Formation by a Swelling Endosseous Implant,xe2x80x9d J. Biomed Mater Res., 12:922-933 (1978). Such implants would, in principle, dilate in a controlled manner by absorption of body fluids to achieve fixation by an expansion-fit mechanism.
Although research on swelling-type bone implants began more than 15 years ago, exploitation of this concept has been largely hampered by the inability to produce a material with the desired hydromechanical properties. None of the previously known materials are made from absorbable hydrogels and all are essentially permanent implants. Also, because there is a degradation in mechanical properties that accompanies swelling, hydration for such materials has been restricted to less than 5-8% by weight and takes place over long periods of time (several days). Since these previous known implants were intended for load bearing applications, low hydration rates clearly were undesirable.
It therefore also would be desirable to provide methods of using and forming hydrogel articles that hydrate relatively quickly, and without substantial degradation of mechanical properties.
In view of the foregoing, it is an object of the present invention to provide methods of using hydrogel articles for sealing or occluding a body lumen, or tissue augmentation, that overcome the drawbacks of previously known devices and methods.
It is another object of this invention to provide methods of using and forming hydrogel articles capable of undergoing a relatively large degree of swelling in-situ.
It is a further object of the present invention to provide methods of using and forming hydrogel articles for plugging voids created in tissue during surgical procedures, such as a needle track created during a biopsy, so as to reduce the risk of hemorrhage after tissue removal.
It is yet another object of this invention to provide methods of using and forming hydrogel articles that hydrate relatively quickly, and without substantial degradation of mechanical properties.
These and other objects of the invention are accomplished by providing methods of using and forming medical articles from pharmaceutically acceptable hydrogel polymer, wherein the articles are introduced in a dry, less hydrated, or substantially deswollen state, and rehydrate in a physiological environment to increase in volume. The methods of the present invention may be advantageously used to affect sealing, plugging, or augmentation of tissue, defects in tissue and organs, and may optionally permit controlled release of therapeutic agents at an implantation site. Hydrogel polymers useful for the present invention may be bioabsorbable or biostable, preferably exhibit a relatively large degree of swelling and rapid rehydration rate, and may include any of a variety of pharmaceutically acceptable or implantable hydrogel biomaterials of natural, recombinant, or of synthetic origin or hybrids thereof.
Methods to form medically useful devices in situ, and to implant devices in accordance with the principles of the present invention in a minimally invasive fashion, also are provided.
In accordance with the present invention one or more rods, plugs, crushed or irregularly shaped pieces of substantially dehydrated hydrogel material are introduced into a lumen or void in a patient""s body to seal or plug a biopsy needle track, serve to reinforce weak tissue, or deliver a therapeutic compound. The hydrogel polymer preferably rehydrates rapidly, within a few minutes of being placed in a moist tissue environment, so as to anchor itself within tissue. During the hydration process, the dried gel may expand volumetrically, e.g., in one, two or three dimensions, to several times its original size, thereby lodging the gel within the tissue and sealing against leakage of fluids through the tissue.
This written description comprises the following portions: a description of hydrogels suitable for use in practicing the methods of the present invention, descriptions of medical articles and methods for using the hydrogel articles of the present invention; and, example compositions of hydrogel articles and exemplary applications.
Hydrogels may be formed from covalently or non-covalently crosslinked materials, and may be non-degradable (xe2x80x9cbiostablexe2x80x9d) in a physiological environment or broken down by natural processes within the body, referred to as biodegradable or bioabsorbable. The breakdown process may be due to one of many factors in the physiological environment, such as enzymatic activity, heat, hydrolysis, or others, including a combination of these factors.
Hydrogels that are crosslinked may be crosslinked by any of a variety of linkages, which may be reversible or irreversible. Reversible linkages may be due to ionic interaction, hydrogen or dipole type interactions or the presence of covalent bonds. Covalent linkages for absorbable or degradable hydrogels may be chosen from any of a variety of linkages that are known to be unstable in an animal physiological environment due to the presence of bonds that break either by hydrolysis (e.g., as found in synthetic absorbable sutures), enzymatically degraded (e.g., as found in collagen or glycosamino glycans or carbohydrates), or those that are thermally labile (e.g., azo or peroxy linkages).
All of the hydrogel materials appropriate for use in the present invention should be physiologically acceptable and should be swollen in the presence of water. These characteristics allow the hydrogels to be introduced into the body in a xe2x80x9csubstantially deswollenxe2x80x9d state and over a period of time hydrate to fill a void, a defect in tissue, or create a hydrogel-filled void within a tissue or organ by mechanically exerting a gentle force during expansion. The hydrogel may be preformed or formed in situ.
xe2x80x9cSubstantially deswollenxe2x80x9d is defined as the state of a hydrogel wherein an increase in volume of the hydrogel of the article or device formed by such hydrogel is expected on introduction into the physiological environment. Thus, the hydrogel may be in a dry state, or less than equilibrium hydrated state, or may be partially swollen with a pharmaceutically acceptable fluid that is easily dispersed or is soluble in the physiological environment. The expansion process also may cause the implanted material to become firmly lodged within a hole, an incision, a puncture, or any defect in tissue which may be congenital, diseased, or iatrogenic in origin, occlude a tubular or hollow organ, or support or augment tissue or organs for some therapeutic purpose.
Hydrogels useful in practicing the present invention may be formed from natural, synthetic, or biosynthetic polymers. Natural polymers may include glycosminoglycans, polysaccharides, proteins etc. The term xe2x80x9cglycosaminoglycanxe2x80x9d is intended to encompass complex polysaccharides which are not biologically active (i.e., not compounds such as ligands or proteins) and have repeating units of either the same saccharide subunit or two different saccharide subunits. Some examples of glycosaminoglycans include dermatan sulfate, hyaluronic acid, the chondroitin sulfates, chitin, heparin, keratan sulfate, keratosulfate, and derivatives thereof.
In general, the glycosaminoglycans are extracted from a natural source and purified and derivatized. However, they also may be synthetically produced or synthesized by modified microorganisms such as bacteria. These materials may be modified synthetically from a naturally soluble state to a partially soluble or water swellable or hydrogel state. This modification may be accomplished by various well-known techniques, such as by conjugation or replacement of ionizable or hydrogen bondable functional groups such as carboxyl and/or hydroxyl or amine groups with other more hydrophobic groups.
For example, carboxyl groups on hyaluronic acid may be esterified by alcohols to decrease the solubility of the hyaluronic acid. Such processes are used by various manufacturers of hyaluronic acid products (such as Genzyme Corp., Cambridge, Mass.) to create hyaluronic acid based sheets, fibers, and fabrics that form hydrogels. Other natural polysaccharides, such as carboxymethyl cellulose or oxidized regenerated cellulose, natural gum, agar, agrose, sodium alginate, carrageenan, fucoidan, furcellaran, laminaran, hypnea, eucheuma, gum arabic, gum ghatti, gum karaya, gum tragacanth, locust beam gum, arbinoglactan, pectin, amylopectin, gelatin, hydrophilic colloids such as carboxymethyl cellulose gum or alginate gum cross-linked with a polyol such as propylene glycol, and the like, also form hydrogels upon contact with aqueous surroundings.
Synthetic polymeric hydrogels generally swell or expand to a very high degree, usually exhibiting a 2 to 100-fold volume increase upon hydration from a substantially dry or dehydrated state. Synthetic hydrogels may be biostable or biodegradable or bioabsorbable. Biostable hydrophilic polymeric materials that form hydrogels useful for practicing the present invention include poly(hydroxyalkyl methacrylate), poly(electrolyte complexes), poly(vinylacetate) cross-linked with hydrolysable bonds, and water-swellable N-vinyl lactams.
Other suitable hydrogels include hydrophilic hydrogels know as CARBOPOL(copyright), a registered trademark of B. F. Goodrich Co., Akron, Ohio, for acidic carboxy polymer (Carbomer resins are high molecular weight, allylpentaerythritol-crosslinked, acrylic acid-based polymers, modified with C10-C30 alkyl acrylates), polyacrylamides marketed under the CYANAMER(copyright) name, a registered trademark of Cytec Technology Corp., Wilmington, Del., polyacrylic acid marketed under the GOOD-RITE(copyright) name, a registered trademark of B. F. Goodrich Co., Akron, Ohio, polyethylene oxide, starch graft copolymers, acrylate polymer marketed under the AQUA-KEEP(copyright) name, a registered trademark of Sumitomo Seika Chemicals Co., Japan, ester cross-linked polyglucan, and the like. Such hydrogels are described, for example, in U.S. Pat. No. 3,640,741 to Etes, U.S. Pat. No. 3,865,108 to Hartop, U.S. Pat. No. 3,992,562 to Denzinger et al., U.S. Pat. No. 4,002,173 to Manning et al., U.S. Pat. No. 4,014,335 to Arnold and U.S. Pat. No. 4,207,893 to Michaels, all of which are incorporated herein by reference, and in Handbook of Common Polymers, (Scott and Roff, Eds.) Chemical Rubber Company, Cleveland, Ohio.
Hydrogels also may be formed to be responsive to changes in environmental factors, such as pH, temperature, ionic strength, charge, etc., by exhibiting a corresponding change in physical size or shape, so-called xe2x80x9csmartxe2x80x9d gels. For example, thermoreversible hydrogels, such as those formed of amorphous N-substituted acrylamides in water, undergo reversible gelation when heated or cooled about certain temperatures (lower critical solution temperature, LCST). Prevailing gel formation mechanisms include molecular clustering of amorphous polymers and selective crystallization of mixed phases of crystalline materials. Such gels, which are insoluble under physiological conditions, also advantageously may be used for practicing the present invention.
It is also possible to affect the rate at which a substantially dehydrated hydrogel rehydrates in a physiological environment, such as encountered upon implantation in an animal. For example, creating a porous structure within the hydrogel by incorporating a blowing agent during the formation of the hydrogel may lead to more rapid re-hydration due to the enhanced surface area available for the water front to diffuse into the hydrogel structure.
When a foamed gel is desired, a two component mixture of the precursors to a hydrogel forming system may be selected such that foaming and polymerization to form the hydrogel are initiated when the two fluid channels are mixed. A double barrel syringe assembly may be provided to mix the fluids, in which each barrel is equipped with a separate plunger to force the material contained therein out through a discharge opening. The plungers preferably are connected to one another at the proximal ends so that a force exerted on the plungers generates equal pressure within each barrel and displaces both plungers an equal distance.
The hydrogel forming precursors for the foregoing system may be selected so that, for example, a free radical polymerization is initiated when two components of a redox initiating system are brought together. One of these components additionally may include a foaming agent, e.g., sodium bicarbonate, that when exposed to an acidic environment (e.g., the other component in the syringe may comprise an acidic solution), releases carbon dioxide as a foaming agent. While the effervescent compound reacts with the water-soluble acid to release gases, the hydrogel structure is polymerizing and crosslinking, thereby causing the formation of a stable foamed gel. Alternatively, other techniques, which are per se known, may be used to foam the hydrogels.
In addition, the driving force for water to penetrate a dehydrated hydrogel also may be influenced by making the hydrogel hyperosmotic relative to the surrounding physiological fluids. Incorporation of charged species within hydrogels, for example, is known to greatly enhance the swellability of hydrogels. Thus the presence of carboxyl or sulfonic acid groups along polymeric chains within the hydrogel structure may be used to enhance both degree and rate of hydration. The surface to volume ratio of the implanted hydrogels also is expected to have an impact on the rate of swelling. For example, crushed dried hydrogel beads are expected to swell faster to the equilibrium water content state than a rod shaped implant of comparable volume.
Alternatively, instead of using dehydrated preformed hydrogels, in-situ formed hydrogels formed from aqueous solutions of precursor molecules also may be used. The hydrogels may be absorbable or biostable. the precursor solutions preferably are selected so that the hydrogels when formed in the physiological environment are below the equilibrium level of hydration. Thus, when formed in-situ, the hydrogels have the ability to hydrate and increase in size. If the hydrogels are formed in confined tissue spaces, the additional swelling is expected to further anchor the hydrogel in place.
Any of a variety of techniques may be used to form hydrogels in-situ. For example, monomers or macromers of hydrogel forming compositions may be further polymerized to form three dimensionally cross-linked hydrogels. The crosslinking may be covalent, ionic, and or physical in nature. Polymerization mechanisms permitting in-situ formation of hydrogels are per se known, and include, without limitation, free radical, condensation, anionic, or cationic polymerizations. The hydrogels also may be formed by reactions between nucleophilic and electrophilic functional groups, present on one or more polymeric species, that are added either simultaneously or sequentially. The formation of hydrogels also may be facilitated using external energy sources, such as in photoactivation, thermal activation and chemical activation techniques.
Absorbable polymers, often referred to as biodegradable polymers, have been used clinically in sutures and allied surgical augmentation devices to eliminate the need for a second surgical procedure to remove functionally equivalent non-absorbable devices. See, for example, U.S. Pat. No. 3,991,766 to Schmitt et al. and Shalaby, Encyclopedia of Pharmaceutical Technology (Boylan and Swarbrick, Eds.), Vol. 1, Dekker, N.Y., 1988, p. 465. Although these previously known devices were intended for repairing soft tissues, interest in using such transient systems, with or without biologically active components, in dental and orthopedic applications has grown significantly in the past few years. Applications of absorbable polymers are disclosed in Bhatia, et al., J. Biomater. Sci., Polym. Ed., 6(5):435 (1994), U.S. Pat. No. 5,198,220 to Damani, U.S. Pat. No. 5,171,148 to Wasserman, et. al., and U.S. Pat. No. 3,991,766 to Schmitt et al.
Synthesis and biomedical and pharmaceutical applications of absorbable or biodegradable hydrogels based on covalently crosslinked networks comprising polypeptide or polyester components as the enzymatically or hydrolytically labile components, respectively, have been described by a number of researchers. See, e.g., Jarrett et al., xe2x80x9cBioabsorbable Hydrogel Tissue Barrier: In Situ Gelation Kinetics,xe2x80x9d Trans. Soc. Biomater., Vol. XVIII, 182 (1995); Sawhney et al., xe2x80x9cBioerodible Hydrogels Based on Photopolymerized Poly(ethyleneglycol)-co-poly(xcex1-hydroxy acid) Diacrylate Macromersxe2x80x9d, Macromolecules, 26:581-587 (1993); Park, et al., Biodegradable Hydrogels for Drug Delivery, Technomic Pub. Co., Lancaster, Pa. (1993); Park, xe2x80x9cEnzyme-digestible swelling hydrogels as platforms for long-term oral delivery: synthesis and characterization,xe2x80x9d Biomaterials, 9:435-441 (1988). The hydrogels most often cited in the literature are those made of water-soluble polymers, such as polyvinyl pyrrolidone, which have been crosslinked with naturally derived biodegradable components such as those based on albumin.
Totally synthetic hydrogels have been studied for controlled drug release and membranes for the treatment of post-surgical adhesion. Those hydrogels are based on covalent networks formed by the addition polymerization of acrylic-terminated, water-soluble polymers that have at least one biodegradable spacer group separating the water soluble segments from the crosslinkable segments, so that the polymerized hydrogels degrade in vivo. Such hydrogels are described in U.S. Pat. No. 5,410,016, which is incorporated herein by reference, and may be particularly useful for practicing the present invention.
Preferred hydrogels for use in the present invention are formed by the polymerization of macromers that form hydrogel compositions that are absorbable in vivo. These macromers, for example, may be selected from compositions that are biodegradable, polymerizable, and substantially water soluble macromers comprising at least one water soluble region, at least one degradable region, and statistically more than 1 polymerizable region on average per macromer chain, wherein the polymerizable regions are separated from each other by at least one degradable region.
Hydrogels that have some mechanical integrity and that cannot be xe2x80x9cextrudedxe2x80x9d from the implantation site by forces applied by natural movement of surrounding tissues are preferred for this invention. Thus, hydrogels suitable for use in the present invention preferably are physically or chemically crosslinked, so that they possess some level of mechanical integrity even when fully hydrated. The mechanical integrity of the hydrogels may be characterized by the tensile modulus at breaking for the particular hydrogel. Hydrogels having a tensile strength in excess of 10 KPa are preferred, and hydrogels having a tensile strength greater than 50 KPa are more preferred.
A number of applications of the foregoing hydrogels are described in accordance with the principles of the present invention. More particularly, use of hydrogel medical articles are described for numerous applications wherein the article inserted with a small profile, and upon hydration serves to occlude lumens, augment tissues or organs, or block orifices.
1. Sealing of Biopsy Tracks
Biopsy needle tracks may be embolized in accordance with the principles of the present invention to reduce complications associated with needle biopsies, such as bleeding and airleaks. A preformed plug of a hydrogel selected as described hereinabove may be placed in a needle track, for example, using the same device that was used for the tissue retrieval.
Specifically, the hydrogel plug is formed from a material exhibiting rapid hydration and swelling, and a low degree of syneresis, i.e., it does not allow absorbed fluid to be easily expelled under moderate mechanical loading. The hydrogel plug may be preformed and partially or completely dehydrated. Upon completion of a biopsy, the hydrogel plug is disposed in the needle track formed by the biopsy instrument. The plug then rehydrates and swells to become firmly lodged in the needle track. The hydrogel plug preferably is bioabsorbable, so that it may be absorbed and allow tissue to eventually fill the needle track. Alternatively, the hydrogel may be formed in-situ, as described hereinabove.
2. Bone Plugs
Bone plugs often are used to occlude the femoral canal during hip replacement surgery. Restricting the escape of uncured bone cement during the insertion of the femoral prosthesis is known to improve penetration of the cement into adjacent spongy bone and ensure complete filling of the canal, including beneath the tip of the device. Plugging the medullary canal prior to cement insertion also aids in compacting the bone cement to eliminate internal voids that may cause cracking and failure of the cement. Apart from the initial cement insertion process, this application is not a load bearing one and is thus ideally suited to the use of an absorbable hydrogel plug. After the cement has set up, within a few hours, the load is borne by the cement.
A rapidly hydrating hydrogel plug that has a xe2x80x9cone size fits allxe2x80x9d capability for intermedullary canals and that does not need any special tools for insertion (drop fit only), may be a convenient tool for orthopedic surgeons. It is expected that a plug of substantially dehydrated hydrogel material may be introduced into the intramedullary canal after the reaming process is complete. The plug will rehydrate within a few minutes to generate a fit sufficiently tight to prevent leakage of the bone cement. Such bone plugs are expected to have significant benefits over previously known non-degradable polyethylene plugs, which form permanent implants.
3. Suture Anchors
Hydrogel articles prepared in accordance with the principles of the present invention may be advantageously employed as bone or cartilage anchors. Suture anchors play an increasingly important role in attaching tendons or ligaments to bone, and are typically made of metallic or other nonbioabsorbable materials. Non-loadbearing indications, such as delicate maxofacial reconstruction or repair of cartilage tears, also may benefit from a soft hydrogel-type absorbable suture anchor. The self hydrating and tightening characteristic of hydrogels may advantageously reduce problems of anchor loosening, migration, interference with imaging studies, and the potential requirement for later implant removal.
For this and the preceding applications, hydrogel material may be threaded or formed around nonabsorbable or absorbable polymer sutures to allow accurate guidance and placement of the devices. In the substantially dehydrated state the suture has a good holding or xe2x80x9cpottingxe2x80x9d strength within the hydrogel article. Upon hydration of the hydrogel material, after the hydrogel is expected to be securely anchored at the surgical site of interest, the suture material easily may be removed. Sutures potted within the hydrogel articles may include single or composite fibers. The shape, form and diameter of the fiber may vary, and may include monofilament, multifilament, twisted thread, spun yarn, staple fiber and whisker.
3. Dental Applications
Hydrogel articles of the present invention also may be advantageously used in dentistry, for example, in occluding root canals. Generally, after a root canal has been cleaned and disinfected, the resulting passageway is occluded to prevent bacterial contamination. Often un-crosslinked rubber-type materials, such as Gutta-Percha, are used to plug these openings. Gutta-Percha, however, has no inherent form-fitting property and must be mechanically forced into the canal.
In accordance with the principles of the present invention, a rod of substantially dehydrated hydrogel material may be cut to size and introduced into the root canal, where it is allowed to hydrate, swell, and lock into place to form a tight fit. The hydrogel is expected to provide an effective barrier against oral fluids, food material, and bacteria. If a substantially non-degradable hydrogel is selected, long term occlusion may be provided. Alternatively, an absorbable material may be used if it is desirable that natural tissues replace the hydrogel over a period of time.
4. Wound Closure
Hydrogel articles of the present invention may be employed for closure of percutaneous catheter puncture sites. Most angiographic, angioplasty, and a variety of other less-invasive catheter based approaches to the vascular system are carried out by cannulating the femoral artery. Generally, a sheath is positioned through a puncture wound to provide access to the artery and allow exchange of various catheters required during a procedure. At the end of the procedure, the sheath is removed, often resulting in a considerable amount of bleeding.
In accordance with well-known techniques, manual pressure is applied to the wound for a period of about 30 to 60 minuted to prevent bleeding and allow cessation of bleeding by clot formation. Even when a clot has formed, the patient is not permitted to freely move around for fear of re-bleeding. Several medical devices, based on collagen-type materials, have been developed to fill the space or track left by the sheath. These materials are however, inherently inflammatory and pro-thrombotic, and may promote intimal hyperplasia or thrombosis of the artery. While various suturing techniques have been developed that use long needles, suture material, and knot pushing devices have been used to close the arteriotomy site, these techniques require considerable skill, especially where visualization of the site is limited.
Hydrogel articles of the present invention may be advantageously used to overcome the drawbacks of previously known wound closure systems. For example, a rod-shaped plug of a substantially desiccated hydrogel may be deployed into the site of an arteriotomy and allowed to hydrate, in the presence of the tissue fluids and blood, to rapidly fill the track of the catheter sheath and prevent further bleeding. By swelling to equilibrium hydration, the plug will lock itself firmly in place and thus reduce the risk of formation of a large hematoma at the site of the puncture.
A hydrogel rod also may be used in conjunction with a pledget configured for intraarterial placement, and that has a suture connecting it to the hydrogel rod. A pledget is a small thin resilient object, formed from polyester foam or felt, that is used to distribute a load imposed by a suture strand to surrounding tissue to prevent tearing, or to reduce bleeding at a puncture site. In this case, the pledget actually provides the arterial closure, but is anchored by the swollen hydrogel within the puncture site. The hydrogel itself may consist of a single rod or alternatively, may comprise a combination of hydrogel shapes, such as braided strands, etc. In the latter case, the resulting macroporous spaces and larger surface area are expected to permit more rapid hydration.
5. Occlusion of Arteriovenous Malformations
Hydrogel articles of the present invention may be introduced into a patient""s body in a low profile, substantially dehydrated state, such that upon hydration the hydrogel article occludes an abnormal vascular structure. Abnormal vascular connections, known as arteriovenous malformations (AVMs), may develop either as a congenital defect or as a result of iatrogenic or other trauma. An AVM may lead to a substantial diversion of blood from the intended tissue and may consequently engender a variety of symptoms, including those leading to morbidity. Subdural hematomas and bleeding also may occur as a result of the presence of an AVM.
Surgical intervention is often undertaken to correct AVMs. Interventional radiologic approaches also are used to obliterate AVMs by embolization, in which the goal of embolization is to selectively obliterate an abnormal vascular structure, while preserving blood supply to surrounding normal tissues. Embolization typically is accomplished using low-profile soft microcatheters that allow superselective catheterization into the brain to deliver an embolic material under fluoroscopic guidance. Various embolic materials have been used in endovascular treatment in the central nervous system, such as cyanoacrylates, ethylene-vinyl alcohol copolymer mixtures (EVAL), ethanol, estrogen, poly(vinyl acetate), cellulose acetate polymer, poly (vinyl alcohol) (PVA), gelatin sponges, microfibrillar collagen, surgical silk sutures, detachable balloons, and coils.
In accordance with the principles of the present invention, substantially dry hydrogel materials may be introduced with a catheter under radiographic guidance to embolize AVMs. Upon delivery to the vascular network, the hydrogel articles, which may be in rod, pellet, fiber, rolled up film or other physical form, rehydrate and occlude the vascular flow by mechanical obstruction. Preferred hydrogel materials to be used in this application should be biostable and not be degraded by the vascular environment. Where permanent embolization is desired, non-degradable hydrogel materials are preferred over degradable ones.
6. Occlusion of Reproductive Organs
Hydrogel articles also may be introduced into the body in a low profile in a substantially dehydrated state such that, upon hydration, they occlude lumens of reproductive structures. For example, the World Health Organization has underscored the need for a rapid and minimally invasive method for female sterilization. Most sterilization techniques used currently are invasive and irreversible. Approximately 40-50% of women age 15-44 that choose to use a contraceptive method are sterilized or their husband has undergone sterilization.
Lack of reversibility and the need for a surgical procedure are major drawbacks of previously known sterilization methods. Ligation of fallopian tubes must to be conducted under epidural anesthesia and is a difficult procedure to reverse. Recently developed scarification techniques involving off-label intrauterine use of Quinacrine have been associated with morbidity and even mortality. There is, therefore a need for a safe and effective way to induce sterilization with a retained option of reversibility.
Catheters to determine the patency of fallopian tubes have been developed, for example by Conceptus Inc., San Carlos, Calif. Ultrasonic inspection for determining the patency of fallopian tubes is a well-known procedure. In accordance with one aspect of the present invention, deswollen hydrogel plug may be inserted intrauterally into the fallopian tubes. When the plugs rehydrate, they occlude the fallopian tubes and readily effect sterilization.
The use of substantially dehydrated hydrogels may permit such hydrogel plugs to be deployed in a doctor""s office setting, without the need for anesthesia. If fertility is to be restored later, the hydrogel plugs may be comprise a biodegradable material that undergoes natural degradation in the physiological environment. Alternatively, the hydrogel plugs may be removed by administration of a solvating agent, or by mechanical removal, and the patency of the tubes restored and confirmed by ultrasound.
7. Sphincter Augmentation
It is estimated that at least 30 million Americans suffer from urinary incontinence. Urinary incontinence may be either temporary or permanent, and result from physiologic or neurologic deficits. Female stress incontinence, i.e., the loss of urine during everyday activities such as laughing, sneezing, coughing, etc., is the most common type of incontinence, and generally responds better to surgery than to previously known drug therapies.
Several surgical approaches have been adopted for the correction of female stress incontinence including urethral slings, bladder neck suspensions, and artificial sphincter implantation. A recent approach to sphincter augmentation uses an injectable collagen as a urethral bulking agent to correct intrinsic sphincter deficiency. Unfortunately, it has been observed that the collagen is resorbed in up to 20% of women within 9 months. Because the procedure is conducted in a minimally invasive fashion, it provides an attractive alternative to intraoperative solutions. There remains, however, a need for a more permanent way to augment the urinary sphincter with a percutaneously administered biocompatible in-situ formed bulking agent and that does not raise pose the safety risks associated with collagen.
In accordance with another aspect of the present invention, substantially dehydrated hydrogels may be percutaneously implanted into the urethral sphincter to create an elastic and tissue-like bulk that lasts several years. Any of the variety of hydrogels described hereinabove have the persistence and in vivo biocompatibility characteristics to be suitable for this process.
A similar approach also may be used to correct other sphincter deficiencies. For example, the gastro-esophageal sphincter may be percutaneously augmented to reduce gastric reflux. The pyloric sphincter also may be percutaneously augmented to reduce xe2x80x9cdumpingxe2x80x9d problems associated with intestinal pH imbalance.
8. Medical Device Coatings
In accordance with another aspect of the present invention, substantially dehydrated hydrogel may be used to coat a medical device, so that hydration of the coating enables the medical device to become anchored in place to prevent migration. For example, stent grafts are wire mesh type devices that are used in conjunction with a textile type woven, knit, or film type material. The wire framework mechanically hold a lumen, e.g., an artery, open, while the textile, fabric, or film provides a lumen through which fluids may flow. This approach has been successfully used in treating aneurysms, such as abdominal aortic aneurysms.
A significant shortcoming of previously known stent grafts systems, however, has been the leakage of blood around the stent graft. This bypass flow often causes the aneurysm to further increase in size, and may lead to eventual rupture.
In accordance with the principles of the present invention, a substantially dehydrated hydrogel coating is disposed on the exterior surface of the textile, fabric, or film of the stent graft. When deployed in a body lumen, the coating hydrates in the presence of blood and tightly wedges the stent graft in position. In addition, as the hydrogel hydrates it causes the stent graft to closely conform to the boundaries of the vessel, so that the blood leakage around the stent graft may be reduced.
9. Delivery of Drugs and Therapeutic Entities
Often the reason for performing a biopsy is the presence of a suspected tumor or other mass of diseased tissue. After confirmation of the biopsy identity, it may be desirable to place a therapeutic agent at the site of suspected disease. The self-anchoring swellable hydrogel articles of the present invention may enable the delivery of therapeutic entities to such sites through the same channel as the instrument that is used to perform the biopsy (or with an instrument having a similar profile).
Optionally, a hydrogel plug, such as described hereinabove, may include one or more biologically-active agents and elute the agent to adjacent or distant tissues and organs in the animal. Biologically-active agents suitable for use include, for example, medicaments, drugs, or other suitable biologically-, physiologically-, or pharmaceutically-active substances that provide local or systemic biological, physiological or therapeutic effect in the body of an animal including a mammal.
Water-soluble drugs that may be incorporated within the hydrogel articles of the present include, for example, peptides having biological activities, other antibiotics, antitumor agents, antipyretics, analgesics, anti-inflammatory agents, antitussive expectorants, sedatives, muscle relaxants, antiepileptic agents, antiulcer agents, antidepressants, antiallergic agents, cardiotonics, antiarrhythmic agents, vasodilators, hypotensive diuretics, antidiabetic agents, anticoagulants, hemostatics, antituberculous agents, hormone preparations, narcotic antagonists, bone resorption inhibitors, angiogenesis inhibitors and the like.
Examples of the foregoing antitumor agents include bleomycin hydrochloride, methotrexate, actinomycin D, mitomycin C, vinblastine sulfate, vincristine sulfate, daunorubicin hydrochloride, adriamycin, neocarzinoszatin, cytosine arabinoside, fluorouracil, tetrahydrofuryl-5-fluorouracil krestin, picibanil, lentinan, levamisole, bestatin, azimexon, glycyrrhizin, poly I:C, poly A:U, poly ICLC, cisplatin and the like.
The biologically-active agent may be soluble in the polymer solution to form a homogeneous mixture, or insoluble in the polymer solution to form a suspension or dispersion. Upon implantation, the biologically-active agent preferably becomes incorporated into the implant matrix. As the matrix degrades over time, the biologically-active agent is released from the matrix into the adjacent tissue fluids, preferably at a controlled rate. The release of the biologically-active agent from the matrix may be varied, for example, by the solubility of the biologically-active agent in an aqueous medium, the distribution of the agent within the matrix, the size, shape, porosity, solubility and biodegradability of the implant matrix, and the like.
The biologically-active agent may stimulate a biological or physiological activity with the animal. For example, the agent may act to enhance cell growth and tissue regeneration, function in birth control, cause nerve stimulation or bone growth, and the like. Examples of useful biologically-active agents include a substance, or metabolic precursor thereof, that promotes growth and survival of cells and tissues, or augments the functioning of cells, as for example, a nerve growth promoting substance such as a ganglioside, a nerve growth factor, and the like; a hard or soft tissue growth promoting agent such as fibronectin (FN), human growth hormone (HGH), protein growth factor interleukin-1 (IL-1), and the like; a bone growth promoting substance such as hydroxyapatite, tricalcium phosphate, and the like; and a substance useful in preventing infection at the implant site, as for example, an antiviral agent such as vidarabine or acyclovir, an antibacterial agent such as a penicillin or tetracycline, and antiparasitic agent such as quinacrine or chloroquine.
Suitable biologically-active agents for use in the present invention also include anti-inflammatory agents such as hydrocortisone, prednisone and the like; antibacterial agents such as penicillin, cephalosporins, bacitracin and the like; antiparasitic agents such as quinacrine, chloroquine and the like; antifungal agents such as nystatin, gentamicin, and the like; antiviral agents such as acyclovir, ribavirin, interferons and the like; antineoplastic agents such as methotrexate, 5-fluorouracil, adriamycin, tumor-specific antibodies conjugated to toxins, tumor necrosis factor, and the like; analgesic agents such as salicylic acid, acetaminophen, ibuprofen, flurbiprofen, morphine and the like; local anesthetics such as lidocaine, bupivacaine, benzocaine and the like; vaccines such as hepatitis, influenza, measles, rubella, tetanus, polio, rabies and the like; central nervous system agents such as a tranquilizer, B-adrenergic blocking agent, dopamine and the like; growth factors such as colony stimulating factor, platelet-derived growth factors, fibroblast growth factor, transforming growth factor B, human growth hormone, bone morphogenetic protein, insulin-like growth factor and the like; hormones such as progesterone, follicle stimulating hormone, insulin, somatotropins and the like; antihistamines such as diphenhydramine, chlorphencramine and the like; cardiovascular agents such as digitalis, nitroglycerine, papaverine, streptokinase and the like; vasodilators such as theophylline, niacin, minoxidil, and the like; and other like substances.
Therapeutic agents that may be delivered may include for example, physiologically active materials or medicinal drugs (such as agents affecting central nervous system, antiallergic agents, cardiovascular agents, agents affecting respiratory organs, agents affecting digestive organs, hormone preparations, agents affecting metabolism, antitumor agents, antibiotic preparations, chemotherapeutics, antimicrobials, local anesthetics, antihistaminics, antiphlogistics, astringents, vitamins, antifungal agents, peripheral nervous anesthetics, vasodilators, crude drug essences, tinctures, crude drug powders, hypotensive agents, and the like).
The terms xe2x80x9ccytokinexe2x80x9d and xe2x80x9cgrowth factorxe2x80x9d are used to describe biologically active molecules and active peptides (which may be either naturally occurring or synthetic) that aid in healing or regrowth of normal tissue, including growth factors and active peptides. The function of cytokines is two-fold: 1) to incite local cells to produce new collagen or tissue, or 2) to attract cells to the site in need of correction. As such, cytokines and growth factors serve to encourage xe2x80x9cbiological anchoringxe2x80x9d of the implant within the host tissue. As previously described, the cytokines may be admixed with the conjugate or chemically coupled to the conjugate.
For example, one may incorporate cytokines such as interferons (IFN), tumor necrosis factors (TNF), interleukins, colony stimulating factors (CSFs), or growth factors such as osteogenic factor extract (OFE), epidermal growth factor (EGF), transforming growth factor (TGF) alpha, TGF-xcex2_(including any combination of TGF-xcex2s), TGF-xcex21, TGF-xcex22, platelet derived growth factor (PDGF-AA, PDGF-AB, PDGF-BB), acidic fibroblast growth factor (FGF), basic FGF, connective tissue activating peptides (CTAP), xcex2-thromboglobulin, insulin-like growth factors, erythropoietin (EPO), nerve growth factor (NGF), bone morphogenic protein (BMP), osteogenic factors, and the like.
The hydrogels of the present invention also may provide controlled delivery of various antibiotics, including, for example, aminoglycosides, macrolides such as erythromycin, penicillins, cephalosporins and the like; anesthetic/analgesic delivery pre-or post surgery or to treat pain using such agents as amide-type local anesthetics like lidocaine, mepivacaine, pyrrocaine, bupivacaine, prilocaine, etidocaine, or the like; and local controlled delivery of non-steroidal anti-inflammatory drugs such as ketorolac, naproxen, diclofenac sodium and flurbiprofen.
In certain forms of therapy, the same delivery system, i.e., hydrogel article, may be used to deliver combinations of agents/drugs to obtain an optimal effect. Thus, for example, an antibacterial and an anti-inflammatory agent may be combined in a single polymer to provide combined effectiveness.
Particular water-soluble polypeptides that may be used in the hydrogel articles of the present invention include, for example, oxytocin, vasopressin, adrenocorticotrophic hormone (ACTH), epidermal growth factor (EGF), transforming growth factor antagonists, prolactin, luliberin or luteinizing hormone releasing hormone (LH-RH), LH-RH agonists or antagonists, growth hormone, growth hormone releasing factor, insulin, somatostatin, bombesin antagonists, glucagon, interferon, gastrin, tetragastrin, pentagastrin, urogastrone, secretin, calcitonin, enkephalins, endomorphins, angiotensins, renin, bradykinin, bacitracins, polymyzins, colistins, tyrocidin, gramicidines, and synthetic analogues and modifications and pharmaceutically-active fragments thereof, monoclonal antibodies and soluble vaccines.
Other beneficial drugs are known in the art, as described in Pharmaceutical Sciences, by Remington, 14th Ed., Mack Publishing Co. (1979); The Drug The Nurse. The Patient, Including Current Drug Handbook, by Falconer et al., Saunder Company (1974-76); and Medicinal Chemistry, 3rd Ed., Vol. 1 and 2, by Burger, Wiley-Interscience Co.
The hydrogel polymers of the present invention may be designed to release appropriate encapsulated, or uncapsulated, growth factors, including epidermal growth factors, human platelet derived TGF-B, endothelial cell growth factors, thymocytic-activating factors, platelet derived growth factors, fibroblast growth factor, fibronectin or laminin.
Useful release rate modification agents may be dissolved or dispersed within the hydrogel material, and include, for example, organic substances that are water-soluble, water-miscible, or water-insoluble (i.e., water immiscible), with water-insoluble substances preferred. The release rate modification agent preferably is an organic compound that substitutes as the complementary molecule for secondary valence bonding between polymer molecules, and increases the flexibility and ability of the polymer molecules to slide past each other. Such an organic compound preferably includes a hydrophobic and a hydrophilic region so as to effect secondary valence bonding. Preferably, the release rate modification agent is compatible with the combination of polymers and solvent used to formulate polymer solution. It is further preferred that the release rate modification agent be a pharmaceutically-acceptable substance.
Useful release rate modification agents include, for example, fatty acids, triglycerides, other like hydrophobic compounds, organic solvents, plasticizing compounds and hydrophilic compounds. Suitable release rate modification agents include, for example, esters of mono-, di-, and tricarboxylic acids, such as 2-ethoxyethyl acetate, methyl acetate, ethyl acetate, diethyl phthalate, dimethyl phthalate, dibutyl phthalate, dimethyl adipate, dimethyl succinate, dimethyl oxalate, dimethyl citrate, triethyl citrate, acetyl tributyl citrate, acetyl triethyl citrate, glycerol triacetate, di(n-butyl) sebecate, and the like; polyhydroxy alcohols, such as propylene glycol, polyethylene glycol, glycerin, sorbitol, and the like; fatty acids; triesters of glycerol, such as triglycerides, epoxidized soybean oil, and other epoxidized vegetable oils; sterols, such as cholesterol; alcohols, such as C6-C12 alkanols, 2-ethoxyethanol, and the like.
The release rate modification agent may be used singly or in combination with other such agents. Suitable combinations of release rate modification agents include, for example, glycerin/propylene glycol, sorbitol/glycerine, ethylene oxide/propylene oxide, butylene glycol/adipic acid, and the like. Preferred release rate modification agents include dimethyl citrate, triethyl citrate, ethyl heptanoate, glycerin, and hexanediol.